Operationalizing Secondary Appraisal

1987; Lazarus, 1999). Lazarus and Folkman measured secondary appraisal with four general items assessing evaluations of whether a situation could be changed, had to be accepted, required more information before acting, and whether self-restraint was required (e.g., Folkman, 1982).

Later researchers have operationalized secondary appraisal as perceived coping resources (Schwarzer & Leppin, 1991; Gall et al., 2005). Following their model, I operationalized

secondary appraisal with three constructs: personal coping resources (generalized positive expectations for the future, or optimism), interpersonal resources (the perceived presence of people to confide in, or perceived social support), and religious coping resources (spiritual beliefs as a cognitive schema shaping perceptions of stress and creating meaning, or

religiosity/spirituality as a proxy). Optimism, religiosity/spirituality, and perceived social support were not reverse-coded because they are already in the direction of higher secondary appraisal (higher coping resources).

2.4.2.a Personal Resource: Optimism

Optimism is the extent to which an individual holds generalized favorable expectations for the future (Carver, Scheier, & Segerstrom, 2010). Adults with higher optimism have been shown to be more persistent in pursuing goals, used more active coping strategies, and had better overall health, which allowed them to translate these tendencies into long-term coping resources (see Carver, Scheier, & Segerstrom, 2010 for a review).

It may be that optimists safeguard their health (preventive or proactive behavior) because they feel more control over outcomes, and thus engage in more health-enhancing behavior (Carver, Scheier, & Segerstrom, 2010). In several cross-sectional studies, breast cancer survivors who reported higher optimism also reported increasing their PA after diagnosis (Harper et al., 2007; Hawkins et al., 2010; Park, Edmondson, Fenster, & Blank, 2008; Park & Gaffey, 2007;

change goals and persevere in these goals because they believe these goals can be achieved, which is similar to Bandura’s work on self-efficacy and positive outcomes expectancies (Bandura, 1986). In another cross-sectional study of breast cancer survivors, women who

expected more positive outcomes (optimistic expectations) from PA itself (e.g., reducing fatigue and depressive symptoms) were more likely to report being physically active after diagnosis (Rogers, Courneya, Shah, Dunnington, & Hopkins-Price, 2007).

Optimism has also been found to be associated with specific coping strategies (Carver, Scheier, & Segerstrom, 2010; Scheier, Weintraub, & Carver, 1986). In the general population, a meta-analysis determined that optimism was correlated with higher levels of engagement coping (coping with a stressor by directly dealing with the stressor to reduce threat or the emotions stemming from it) and lower levels of disengagement or avoidance coping (escaping the stressor or emotions stemming from it) (Solberg Nes & Segerstrom, 2006).

There is evidence that this is also true for breast cancer survivors with higher optimism. Namely, Carver et al. (1993) observed that before and after surgery, breast cancer survivors who were more optimistic used more coping that involved accepting the reality of the situation, placing a positive light on the situation, and relieving tension with humor, which resulted in lower distress. Breast cancer survivors who were more pessimistic used more coping strategies focused on overt denial (pushing the reality of the situation away) and were more prone to giving up on goals (Carver et al., 1993). Thus, optimism can be viewed as an indicator of secondary appraisal because a woman has favorable expectations that she has the resources necessary to support active coping and feels more control over coping resources.

expectations. For instance, one LOT statement is, “I’m always optimistic about my future.” I also operationalized optimism with the LOT.

In sum, optimism is a generalized positive expectation about the future, which can be situation-specific (e.g., medical contexts) and clusters with other coping resources such as social, status, and economic resources. Optimism can be an indicator of secondary appraisal because an individual who feels that she has the resources necessary to support a coping strategy may also feel more control over the situation. This supports using optimism as a proxy for secondary appraisal.

2.4.2.b Interpersonal Resource: Perceived Social Support

Perceived Social support is a multidimensional construct encompassing emotional, tangible, and informational functions. Lazarus and Folkman conceptualized social support as a coping resource because it is a transactional process that changes with demands of a stressor (1987). This conceptualization is consistent with the view of perceived social support as an indicator of secondary appraisal, that is, women who perceive that they have support available to them if they need it are more likely to view a stressor as something they can cope with

successfully.

Social support has been extensively studied in the context of stressors and chronic health conditions. In the 1980s, health psychology researchers were examining the ways in which social support impacts chronic health conditions. Cohen and Wills popularized the “buffering

hypothesis” in their review of social support models (1985). This hypothesis states that the positive association between social support and health/well-being is attributable to a process through which support protects individuals from potentially adverse effects of stressful events. In other words, social support is predicted to “buffer” against stressors (Cohen & Wills, 1985), and

to be relevant for breast cancer survivors. Waters and colleagues (Waters, Liu, Schootman, & Jeffe, 2013) found that early-stage breast cancer survivors who reported higher perceived social support experienced better perceived health in the first six months after diagnosis and had a shorter recovery period than women with lower social support. Perceived social support also predicted 5-year trajectories of PA for breast cancer survivors (Emery et al., 2009).

In the HEAL study, an item assessing confidant network size was available as a proxy for perceived social support. This item assesses how many family or friends the woman confides in. The item assumes that a larger confidant network represents greater perceived social support. It was administered at 39 months post-diagnosis. At that time, breast cancer survivors were also asked to recall their number of confidants at the time of diagnosis. Given that breast cancer survivors were recalling past perceived support, recall bias may be an issue. Women may have remembered better or worse perceived social support at the time of diagnosis than was actually the case. See Cohen, Underwood, & Gottlieb (2000) for a discussion of social support measures and test-retest reliability.

2.4.2.c Religious Coping Resource: Religiosity/Spirituality

Religiosity/spirituality functions as a coping resource in three ways: 1) it provides a schema for that helps people achieve an understanding of adversity to facilitate cognitive

processes and situational meaning making (i.e., a way of comprehending a stressor in relation to attitudes and beliefs about the world and a higher power); 2) it increases feelings of control over a stressor (e.g., a belief that “God is in control” or “God has a plan”); and 3) it may provide emotional, tangible, and informational support resources for individuals who are part of faith communities (see Harrison et al., 2001 for a review). Therefore, religiosity/spirituality is

In a qualitative study with breast cancer survivors, religiosity and spirituality were reported to be critical aspects of HRQOL and experiences in the post-treatment period. Breast cancer survivors described religiousness and spirituality as playing three major roles:

1) providing global guidance; 2) guiding illness management efforts; and (3) facilitating recovery (Puchalski, 2012; Regan Sterba et al., 2014; Schreiber, & Brockopp, 2012). Women’s religious and spiritual beliefs and behaviors were used to cope with breast cancer in terms of making sense of the illness and to manage the physical and emotional aspects of breast cancer (Puchalski, 2012; Regan Sterba et al., 2014; Schreiber, & Brockopp, 2012). The ability to create meaning when faced with a stressful event has been associated with successful coping, adaptation, and well-being in both cancer and non-cancer populations (Koenig, 1997; Park & Folkman, 1997; Schreiber, & Brockopp, 2012). In contrast, the inability to find meaning during a stressor has been correlated with psychological distress and uncertainty, which in turn can lead to inhibition of effective coping behaviors (Koenig, 1998; Pargament, 1997).

In the HEAL study, religiosity/spirituality was measured with the Duke Religion Index (Koenig, Parkerson, & Meador, 1997), which assesses religiosity/spirituality in terms of organizational, individual, and intrinsic religiosity. The items include: 1) “How often do you attend faith community or other religious meetings?” 2) “How often do you spend time in private religious activities, such as prayer, meditation or Bible study?” 3) “In my life, I experience the presence of God or the Divine”; 4) “My religious beliefs are what really lie behind my whole approach to life”; and 5) “I try hard to use my religion in all aspects of my life.” In the general population, religious/spiritual beliefs have been correlated with an active attitude toward coping, higher perceived social support, and more hopeful attitudes in response to a stressor (Koenig,

1997), which supports my decision to include religiosity/spirituality as one of three proxies for secondary appraisals.

In sum, religiosity/spirituality is a good proxy for religious coping resources because it provides a schema for making sense of adversity, increases feelings of control over a stressor (e.g., a belief that “God has a plan”), and, for individuals who are part of faith communities, enhances the potential real or perceived availability of support resources.